Dear Dr. Khan,
I have bad breath. My father also had the same problem. Do you think the tongue is one of the major sources of bad breath? Should I use mouthwash, and what kind of mouthwash is better? When is the best time to rinse? Please elaborate. - Solaiman

Dear Mr. Solaiman,
In healthy people, the tongue is probably the major source of bad breath. You may not believe such a statement. Many people have coatings on their tongues, and some researchers have implicated the coating as a source of bad breath. Having a coating on your tongue does not necessarily mean that you have a yeast infection (Candida) or bad breath.
In many people with bad breath, a careful scraping of the back of the tongue with a spoon reveals a yellowish mucous material. And while it may not have a smell when it gets there, after hanging around for a few days, the millions of bacteria on the tongue break it down, yielding foul smelling molecules.
Perhaps in more primitive societies the back of the tongue was cleansed by eating more fibrous food than we do today. Whether or not this is true, the back of the tongue is a major source of bad breath, and the odour that it gives off has a typical smell of its own.

When is the best time to rinse?
The best time to use any mouth rinse appears to be right before bedtime. Since in many instances, bad breath involves the back of the tongue, it is probably helpful to gargle the rinse. Some clinicians recommend extending the tongue while gargling, in order to allow the mouth rinse to reach farther back.

How do I know when I have bad breath?
Some people who come to malodour clinics claim that they can smell their own breath. They do this in a variety of ways, some ingenious. The most common thing to do is just to cover your mouth and nose with your hands and take a deep whiff. Some people are able to detect odour in this manner.

An easier thing to do is to lick your wrist. Some people smell their odour on the telephone receiver after a conversation. Others rub their gums with their finger and smell it. One woman claimed to be able to smell her own bad breath by covering her head with a blanket.

The problem with all these techniques is getting an objective viewpoint of the odour coming out. In a recent study, we asked 52 to smell their own bad breath and score it on a scale. In general, the results showed that people were unable to score their own bad breath in an objective fashion.

This is probably because we all have a certain preconception of how bad our breath smells, and when we come to score what we smell, we are heavily influenced by our mindset, regardless of how bad the smell actually is. Several years ago, a Japanese company came out with a little bad breath detector that looks like a small powder box, mirror and all. But when you open it, there are little buttons and lights that go on and off. You blow over a small grid, and within several seconds it gives you a score.

However, there is a serious question as to whether these small instruments are at all accurate. Most people have bad breath at one time or another. The best way to find out if your have it on a regular basis, is to ask someone close to you. Provided that they love you, and that they have a sense of smell, family members will find a way of telling you the truth. You can also ask a very close friend.

Do your gums bleed?
If your gums bleed spontaneously (when you wake up in the morning), when you eat an apple or banana, or even if they bleed when you brush them, then you should know that this may be a sign of gum (periodontal) disease. Gum disease is caused by odour-forming bacteria and is related to bad breath in at least some people.

If you don't take care of gum inflammation at its early stages, it may develop into more severe stages, which are irreversible, and can eventually lead to having your teeth loosen and fall out. If your gums bleed, you feel that your teeth wobble, or your teeth exude a terrible taste, take care of them immediately.

The best bet is to go straight to a periodontist. If an operation is recommended, a second opinion should be obtained. The success of periodontal therapy depends, above all, on how the patient improves his/her oral hygiene on a day-to-day basis.

Is having your teeth pulled a remedy for bad breath?
No! I once met a woman who, during the 1950's had all her teeth pulled by a dentist (in Canada!) in order to cure her from having bad breath. In 1990, she still had bad breath (from her tongue!). Don't make the same mistake. Keep your teeth (unless several dentists have told you that they are hopelessly beyond salvation), they're precious. When you get your dentures, make sure to consult your dentist on how best to take care of them, including how to prevent them from taking on odour.

Should I use mouthwash, and what kind of mouthwash is best for maintaining oral hygiene?
Mouthwashes were invented several thousand years ago for breath freshening. One concoction consists of dough water, salt and olive oil. Commercial mouthwashes usually contain a concoction consisting of flavour, alcohol, and antibacterial agent(s). Several types of mouthwash have been shown to reduce malodour in clinical trials, including 0.2% chlorhexidine mouthrinses 1% povidine iodine.

Sprays and regular mint candies are considered to be relatively ineffective in combating bad breath. Don't be fooled by the burning sensation - it is your own cells in pain, not the bacteria.

Bad breath from the stomach
Bad breath from the stomach is extremely rare. The oesophagus, which connects the stomach with the mouth, is not an open tube, but is closed. Each chunk of food (called a bolus) moves down the oesophagus similar to the way that a swallowed frog moves down a snake. Similarly, when one belches, a little bubble of air moves up the oesophagus and exits at the mouth. I am not trying to argue that belches don't smell. They can and do. It's just that belching is a once-in-a-while phenomenon. The rest of the time, the oesophagus closes off the stomach.

Some people think that the tongue and stomach are connected, perhaps through reflux of liquid. Although I cannot completely rule that possibility out, the smell of tongues has little in common with stomach odours.

Furthermore, bad breath can usually be controlled by treatments limited to the mouth itself.
From my experience, when bad breath strikes, the stomach is the last place to look for an answer. In my opinion, a gastroenterologist who performs a gastroscopy when a patient complains solely of bad breath, instead of first sending the patient to a dentist and otolaryngologist, is not practising good medicine.
The above notwithstanding, both Islamic and Jewish teachings mention the stomach as being involved in bad breath. In the Talmud, it is taught not to indulge in eating raw peas. Similarly, Rashi recommended that one walk a little following the meal, in order to prevent bad breath. We cannot rule out the possibility that in ancient times, some foods or habits (perhaps eating in a supine position) were more likely to result in continuous belching).

Perhaps the ancient religious lore is responsible for the common misconception that bad breath is primarily a stomach thing.

Bacteria in and around the gum line
Some people don't accumulate dental plaque and calculus. They are few and far between. Most of us need to visit hygienists to get our teeth cleaned periodically. As hygienists can tell you, the smell of what comes out between our teeth and our gums is awful. These areas are perfect hiding places for bacteria.

The bacteria that grow beneath the gum line are a combination of those that use oxygen and those that can grow only when the oxygen is gone. These two kinds of bacteria live in harmony, the first type consuming the available oxygen, and the second kind taking advantage of the oxygen- free environment.

This second kind is generally considered to be responsible for the smell - a fierce combination of volatile sulphur compounds, combined with a variety of others, possibly including nitrogen-containing gases such as cadaverine (smell of corpses) and putrescine (smell of decaying meat).

Prayer

I Went to the mosque the other day. It was mid afternoon. Somewhere between Zuhr and Asr. The afternoon, like most, was lazy. The beggars in front of the mosque were using their hands to eat and not asking for mercy, money or miracles when I walked in.

The last time when I had been to a mosque in Bangladesh I was five years old. It was Eid and I had gone with Baba. We prayed next to each other while my dupatta kept on getting tangled around my tiny body. Most of my energy went into playing the game of trying to be in sync with the rest while their bodies moved from standing to kneeling.

But this afternoon was different. I wasn't looking to play the game of putting my body or mind in sync with others and celebrate, I wasn't there because I had special requests for God or men. I was there just because a friend asked if I would join and I felt curious and without thinking much said yes.

The courtyard had flowers; it had cats meowing around and people chatting in different corners. I walked up to the women's section. A small lock hung from the sliding door. I found a man taking a shower next to the building, without stopping his bath he told me to go ask the security guard for the keys.

I found the security guard next to the madrasa children; he was taking an afternoon nap. A long beard hung from his face, his forehead had a mark from all the sejdas he had given during his long life. I hesitated as I wondered how he might judge me.

In the middle of my thoughts he woke up, seeing me staring at him he sprung up and apologized for keeping me waiting. I told him I needed the keys. Hurriedly he took them out and walked with me to the building and opened the gate. I walked in and he said he would wait so that no one steals my shoes.

I stepped in bare foot, a whole building to myself. I washed all my visibles and found a corner, my reflection beamed at me from the glass windows. I prayed while the sun lowered on the sky and a man waited guarding my sandals.

When I came out he smiled and lifted up my shoes. I put them on, he locked the door and told me “bhalo thaiken apa.” I nodded.

I walked up to the garden and sat down, waiting for my friend to finish his prayers. An old dying cat came towards me and sat near my feet. She coughed like a human; death danced all over her morbid face. I petted her while she coughed more. And somewhere between dying in a lazy afternoon we exchanged our gratitude, to the mosque, her last shelter and my lost one.

By the way

A potpourri of herbs

There are many ways of using herbs: potpourri and herb teas are traditional ways to soothe jagged nerves. And a bunch of herbs mixed with cottage flowers will brighten up any kitchen or bathroom windowsill.